EM Clerkship: Approach to Overdose/ Poisoned ED Patients

1. EM Clerkship: Approach to Overdose/ Poisoned ED Patients

2. Objectives • Describe US Poison Systems/Services • Poison Epidemiological Highlights • Describe common Toxidromes • Describe Indications for Tox Screens and other diagnostic tests • Describe GI Decon Options, Indications • List Common Antidotes

4. 800 222-1222Regional Poison Centers • Major Med Centers/ High Call Volume • Many Toxicological Info Resources • Available 24 hr/d, 7 d/wk • Certified Specialists in Poison Info • Med Tox Board Certified Backup • Follow Up Calls - Determine Outcome • AAPCC National Poison Data Base (NPDS)

5. 1995 US Poisonings Exposures 2,400,000 ED Visits 1,000,000 42% Hospitizations 215,000 9% Deaths 18,549 <1% 80% DOA

6. Fatal Accidents SEA/KC 2008 S/KC 2008 Medical Examiner Report

7. “Recent changes in drug poisoning mortality in US by urban–rural status & drug type” • Paulozzi LJ: Pharmacoepi Drug Safety 08 • 99 - 04 Nonsuicide drug poisoning deaths 62% •  Primarily due to prescription opioids. • By 04, prescription opioids caused more deaths than either heroin or cocaine

8. 1.5

9. Basic Approach to the poisoned patient Stabilization History and Physical Exam Diagnostic tools Measures to reduce absorption Measures to enhance elimination Specific antidotes Supportive care

10. Stabilization • Airway, Breathing, Circulation • DON’T regimen • Dextrose (or rapid finger stick glucose check) • Oxygen • Naloxone • Thiamine • EKG

11. History and physical • History and Physical • Info from family/friends/EMS/Police • Look for signs of toxidromes • Consider GI decontamination and enhanced elimination • Call the poison center • Assistance with management • Reporting and surveillance

12. Toxicologic focus physical exam • Vital signs • Mental status – depressed or agitated? • Eyes- miosis or mydriasis • Skin/Axilla/Mucus membranes-moist or dry?

13. Toxicologic focused exam cont. • Respirations -Increased or decreased rate/adventitious sounds? • Bowel sounds -Present? Absent? • Neuro -Rigidity, hypo/hyperreflexive?

14. Toxidromes • Toxidrome: Cluster of clinical sign and symptoms that can help identify a toxin and aid in the management of a poisoned patient. • Types of Toxidromes • Opioid • Sedative/hypnotic • Sympathomimetic • Anticholinergic • Cholinergic

15. Case 1 • Case: 29 year old male is found lying on the floor of a bathroom of a gas station. • He is somnolent and responds only to deep stimulation • His respiratory rate is 6 with • shallow breaths • Pupils are pinpoint • Track marks are noted • What toxidrome is this?

16. Opoid toxidrome • Opioid toxidrome • Miosis, usually • Respiratory depression • CNS depression • Treatment • Oxygen and airway management • Assisted ventilation • Naloxone? • Intubation • The main culprits: • Heroin • Prescription narcotics (methadone/vicodin/ oxycodone/etc.)

17. Case 2 • A 39 year old female well known to EMS and ED for alcohol abuse is found sleeping in the street by police stating she took some “stix” • She is somewhat sleepy but answers questions appropriately with slurred speech. Vitals are normal, pupils are 3mm reactive bilateral She shows horizontal nystagmus on visual testing What toxidrome is present?

18. Sedative/hypnotic toxidrome • Sedative/hypnotic toxidrome • CNS depression • Respiratory depression (sometimes) • Nystagmus • Normal to dilated pupils • Treatment • Largely supportive • Extreme caution with antidotes • Main culprits -ethanol -benzodiazpines (lorazepam/diazepam/clonazepam etc..) -barbiturates (phenobarbital)

19. Case 3 • 24 year old male is found by police wildly agitated and threatening and is not restrained by 4 large officers after kicking out the windows of a police cruiser. • His pupils are markedly dilated and he is diaphoretic and tachycardic • Between insults and threats, he complains of chest pain What is your initial management ? What is this toxidrome?

20. Sympathomimetic toxidrome • Sympathomimetic toxidrome • Agitation to aggressive behavior • Seizure • Dilated pupils • Increased pulse and respiratory rate • Rigid and febrile in severe cases • Examples: • Cocaine (crack/powder) • MDMA (ecstasy) • Methamphetamine • PCP (sherms) • Treatment • Support • Sedation (benzodiazepines!)

21. Case 4 • 17 year old high school senior is found mumbling and hallucinating after ingesting jimson weed seeds. • Pupils are dilated • Skin is red and dry • He has decreased bowel sounds and a full bladder

22. Anticholinergic toxidrome • Anticholinergic Toxidrome • Dilated pupils • Dry, flushed skin • Dry, mucous membranes • Sedation agitation and hallucinations • Urinary retention • Examples: • Benadryl • Phenergan • Jimson weed • Scopolamine • Treatment • Support • Sedation (benzos)

23. Case 5 • 35 year old migrant farm worker is found in respiratory distress and vomiting. He was spraying the fields with an unknown chemical today without a mask. • His saturation on room air is 92% and he has rales and wheezing bilaterally • Pupils are pinpoint and he is somewhat agitated • What is this toxidrome?

25. Cholinergic Toxidrome SLUDGE DUMBELS Defecation Urination Meiosis Bronchorrhea Emesis Lacrimation Salivation • Salivation • Lacrimation • Urination • Defecation • GI cramping • Emesis

26. Cholinergic Toxidrome Treatments Main Culprits Organophosphate pesticides Nerve gas • Decontamination • Atropine • 2-PAM • Supportive care

27. Putting it all together

28. Toxicology Evaluation • Serum labs • Chem 7 (look for anion gap), osmol, ABG if indicated, HCG • Quantitative levels • Tylenol, aspirin, lithium, seizure meds (dilantin, VPA, tegretol), digoxin • Urine toxicology • Send if helps with diagnosis or management • EKG

29.  Anion Gap Acidosis • Methanol, Metformin • Uremia • Diabetic Ketoacidosis • Paraldehyde, Phenformin • Idiopathic, Iron, Isoniazid • Lactic Acidosis (Cyanide) • Ethylene & Other Glycols • Salicylate, Strychnine

30. “Double Gap Acidosis” • Screens for toxic alcohol poisoning • Anion Gap • Na - (Cl + HCO3) • Normally < 10 • Osmolal Gap (OG) • (2*Na) + (Gluc/18) + (BUN/2.8) + ETOH/4 • Normally < 10

31. Ethanol Ethylene Glycol* Isopropanol Methanol* Acetone Ketoacidosis* Renal Failure* Mannitol Sorbitol Hyperlipidemia Hyperproteinemia Increased Osmolal Gap * Double Gap Acidosis

32. Main GI Decon Options • None • First, do no harm • Gastric Lavage • Activated Charcoal • Whole Bowel Irrigation

33. Gastric Lavage • Indications: • Life threatening OD or pharmacobezoar • Contraindications: • Unprotected airway, hydrocarbon or caustic ingestions, esophageal pathology • Complications: • Aspiration  Hypoxia, Pneumonia • Kinked Orogastric Tube • Perforation (throat, esophagus, stomach), laryngospasm, epistaxis, great discomfort

34. With LOC Protect Airway - Rapid Sequence Intubation

35. Activated Charcoal • Indications: • Potentially adsorbable toxic OD presenting < 1-2 hr after ingestion • Contraindications: • Unprotected airway, non adsorbable toxin (metals, caustics) • Dose: 1 gm/kg up to 50 gm

36. Whole Bowel Irrigation WBI • Very little literature available • Indications: • Sustained release, enteric coated, heavy metals • Contraindications: • Bowel obstruction, perforation, ileus; unprotected airway, dehydration

37. Multidose Activated Charcoal (MDAC) Enhanced Elimination Serial dosing of activated charcoal Enhance elimination by interruption of entero-enteric circulation Consider in ingestion of: Phenobarbital Salicylates Theophyline Carbamazepine Digoxin Phenytoin

38. Hemodialysis Utility depends on toxin physical characteristics -size -high water solubility -low protein binding -small Vd (volume of distribution) • Salicylates • Phenobarbital • Methanol • Ethylene glycol • Lithium

39. Hyperbaric oxygen • Potential benefit in carbon monoxide (CO) poisoning • Increase dissociation of CO from carboxyhemoglobin • Consider for highly symptomatic patients or pregnant patients with CO poisoning

40. Common Antidotes

41. Supportive care • Continual re-assessment of patient stability (don’t forget the ABCs!) • Psychiatric care and precautions for suicidal patients

42. In Summary • Initial stabilization • Complete history and physical (as possible) • Identify toxidromes if present • Call poison control for guidance • Utilize tests as indicated • Determine whether GI decontamination/enhanced elimination is indicated • Antidotes • Continual re-assessment/supportive care